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Kiff, J A (2006e)
Paper 5: Resolving the tension between the Scientist Practitioner and the Reflective Practitioner models Joe Kiff, Dudley South PCT Introduction We are now in the position of comparing and contrasting the strengths and weaknesses of both a scientist practitioner and the reflective practitioner models as they reflect the logical empiricist and post-modern paradigms. Table here needs formatting Scientist Practitioner Model Based on: Reflective Practioner Model Based on: Classical science Post-modern Science Knowable reality Unknowable ‘reality’ Quantative studies Qualitative studies Objective Stance Subjective stance Deductive logic Inductive logic Mastery model Collaborative working Emphasis on Rational thinking Emphasis on Metaphorical thinking. In this paper I hope to explore this tension in the light of my own understanding of my own psychology, to indicate how the two ways of thinking and working have been integrated into my clinical practice, mediated by my own temperament and learning history. In doing this I make no claims for the superiority of my own position, but simply invite others to make the same analysis whilst acknowledging any differences between us. In terms of Kiersey’s model I have an introverted, intuitive, feeling, perceiving temperament. (INFP Type) Being very introverted my natural interactive style is to be a listener rather than a talker and I naturally fall into a collaborative counselling style and find the requirements of a more active ‘do to’ interactive style alien and suspect. The mastery model underpinning the scientist practitioner paradigm does not sit easily with me because I am used to working with the realities of others and generally do not seek to impose my own view in my everyday interactions. The idea that scientific evidence should empower me to structure a conversation in concrete ways and have the confidence to leverage people into clinical protocols is to me distasteful, I have never found it a convincing way for me to behave. To work in this way one usually needs to be more convinced of the inherent objective, knowability of the world which comes more naturally, I think, to concrete, extrovert people who are used to structuring their interactive world through their own pronouncements. The emphasis that a post-modern approach places on plural, subjective realities, unknowability and an analysis of social power is very attractive to me. This has helped me to construct a fresh understanding of my own practice, and to revalidate my own approach. Where my scientist practitioner training has left its mark in me is that I more readily move towards negotiating mutual goals with people and over the years have learnt to be more confrontative and less passive in my interactions in the service of clinical progress. Being intuitive rather than sensing in Kiersey’s terms means that I have a tendency to emphasise the context rather than the concrete ground. I am naturally drawn to understand the abstract connections behind phenomena. It has always seemed artificial to me for positivist science to define symptoms as the problem and to operationalise interventions to the point where they rule out real life, spontaneous interaction. In my own clinical model there is a place for working on the basis of such evidence but only in particular limited clinical contexts. My inductive turn of mind and tendency to collaborative working means that we very often end up reframing people’s symptoms as marginal indicators of more serious underlying difficulties that they had not been able to face internally and/or communicate. Being predominately a feeler rather than a thinker, has been the biggest barrier to my socialisation into the scientist-practitioner model. How we could develop a clinical psychology that relegated feelings to a peripheral position as an internal state not easily operationalised has simply always struck me as nonsensical. I could not make sense of it in the light of my lived experience. A reflective practitioner model allows me to honour my feelings and to value them as critical tools for the way I work as a clinician. With this preference I understand myself to be right hemisphere dominant and with this has come a preference for metaphorical rather than literal thinking which has facilitated my interpretation of peoples symptoms as signs of other problems. The logical procedures of a quantative scientific approach simply do not convince me in the way that qualitative studies. In truth I experience many positivist experimental papers as aversive. I simply do not support the assumptions about the world that they try to draw me into. On the other hand I could spend hours going over discourse analysis of sessions. When Marzillier (2004) writes in ‘The Psychologist’, * "In over 30 years of psychotherapeutic work not one outcome study has influenced my practise to any significant degree" he speaks for many of us. Is science of so little use in guiding clinical practice? I feel it is important not to overstate the case and, as he points out, science provides useful ways of thinking about phenomena, but it can no longer be regarded as the primary basis on which it is appropriate to act clinically. Being an accepting perceiver rather than an analytic judger affects me in two main ways. Firstly, in terms of scheduling I am not in favour of too much structure within the therapeutic boundary. I do not advocate session plans, keeping of activity diaries and the like, preferring to emphasise spontaneity and the following of the material. Paradoxically perhaps I am particularly tight on boundaries but I do this to make it safe for us to be flexible in the session. Secondly, I find it hard to be critical of people; my strength is unconditional positive regard, my weakness is gullibility in initially accepting people’s accounts of events etc. But with the lack of a critical, defining, objectivity I experience my own position as ethically in tune with the people that I see. I am not divorced from them by knowledge and power, I am not alienated from them because they are not objectified as a symptom, I do not judge them and relate to them on more equal terms. Such values are important to me and I feel they are compromised in me when I am pressured to work in the scientist-practitioner mode. It seems to me that upon qualifying from clinical training we are faced with the problem of applying research based on inflexible generalisations about groups to the difficulties faced by unique individuals. This involves a leap from concrete thinking (rigidly applying theory without sufficient discrimination) to developing a self aware, creative and flexible style to meet the needs of the individual person seeking clinical help. In my own experience this has involved a process that has moved me away from a scientist practioner model of working towards a reflective practioner model. As we have seen in previous papers in this series: positivist science, as a system for generating knowledge, is too narrow. When we were young, both as a science and as practitioners that was all we had. But now there are a growing number of us who have accumulated many hours of experience, who have sat conscientiously listening to people’s accounts of their lives, trying to make sense of them; taking seriously the notion of a learning history. Through curiosity we have been led, by necessity, to accommodate new information, to develop working practices that incorporate ideas, techniques and perspectives from a wide variety of sources, in order to achieve clinically effective ends. By now we have many subtle ways of saying things, a large collection of clinical tactics and strategies, a variety of language systems within which we can present ideas, and an alert, sophisticated framework within which to process feelings. In our relationship with clients decisions are made out of a deep understanding, accumulated through our experience, when we try to say and do the things that a particular person will find clinically useful. Hardly any of this is based on unambiguous scientific evidence. By its nature much of it is ephemeral, arising out of intuition, just as Schon (1983) describes. When I started training I subscribed to the view that science would help me understand the reality of people. As the course progressed it became clearer that I was uncomfortable with the rational view of the world and that this was in conflict with my emotional, intuitive, metaphorical, personal way of relating, both to myself and to the world. To this degree the socialisation of myself into the strictly positivist tradition partially failed. While I have used the techniques derived from this intellectual tradition I have done so on a pragmatic basis and have throughout my career sought for a clarification of my own position, which I have laid out in these papers. What has become clear over 20 years of supervising others and running personal development groups is that many other clinical psychologists struggle similarly to submit to the positivist yoke. Their personal values are at odds with the assumptions of reality implied by a strict adherence to the scientist practitioner model and they try to find another way forward, (for example, through psychotherapy training) I have tried to resolve this tension for myself by working within the scientist practitioner model where this makes sense to me and the people I try to help, but work on a reflective basis where intuition and integrative performance are required in minute-to-minute therapy. Thought Experiment It might be helpful at this point to introduce a thought experiment in the spirit in which they are used in philosophy and quantum physics theorizing. Suppose we have two clinical psychologists A & B and two people seeking their help, Y & Z. Psychologist A is a rational thinker, brought up by similarly genetically endowed accountant parents. Inclined to the obsessional, emphasising detail to see the wood for the trees. Is somewhat stiff in personal relationships and given to thinking deductively from the particular and seeks to exercise social power through logical argument, backed by appeals to evidence. Her response to training has strengthened this tendency in her and she is widely regarded as a conscientious expert. Psychologist B is a natural intuitive, adept at interpreting the language, history and behaviour of others. Drawn to the big picture, inclined to extrapolate inductively at will from the particular to the general, and back again. Charismatic and charming with an easy social manner, he is able to generate and tolerate strong feelings in others. He too is recognised and admired as an expert clinician. Client Y is a man with clear obsessional problems. He struggles with numbers and borderlines. He comes from a good no nonsense professional family who have supported and encouraged him in his career as a highly qualified designer and engineer. Client Z is an artist with a strong interest in dreams and the occult. For many years she has struggled with depression. She comes from a broken home, within which she was sexually abused, and has a somewhat chaotic relationship with her current partner and their three children. One doesn’t have to be a psychologist to see that the psychologists are going to be offering a different experience to their clients and that in all likelihood Psychologist A and Client Y are compatible and will find common ground working out of a scientist practioner informed therapy, while Psychologist B and Client Z will naturally settle into a spontaneous and conversational therapy more informed by the reflective practioner model. The difficulty is more likely to arise when we cannot so easily pick who we see. How is psychologist A going to bridge the gap in assumptive worlds with client Z and how is psychologist B going to be able to do work that is useful for client Y. The issue isn’t really whether we work out of one model or the other, but rather that sophisticated level three work requires that we are skilled and flexible enough to tailor what we offer to the language, values, attitudes, social assumptions, emotional and cognitive capacity of the people we are trying to help. Few of us can easily balance the competing dichotomies in our nature and it usually means that we have to go through a process of first committing ourselves to the way of working that makes sense to us and then at a later date turn to the neglected other side of the equation. We can avoid this pressure by specializing, but it is important then to honour what we do not know and to respect the limits of our own practise and the legitimacy of others who work in a different way from us. Too often I see clinical psychologists steeped in the theory and practice of an approach conducive to their own learning history and personality, convinced that their way of working is the correct way and inclined to feel that their approach will suit everybody they see. They are distrustful, if not dismissive, of others practicing differently, out of different life experiences, personality and values. The intertwining of the personal and the professional, when not properly separated through reflective awareness, impairs and narrows judgement, this restricts intellectual debate, clinical flexibility and professional understanding. Conclusion In comparing and contrasting the scientist practitioner and the reflective practitioner model I hope I have been able to demonstrate that a useful integration can be achieved between the two approaches. We should expect any competent psychologist not only to account for their treatment methods in terms of a coherent, socially validated model, supported by scientific evidence where appropriate, to supplement this with a commentary on the therapeutic process, indicating their awareness of the various contexts relevant to their and their clients performance, including their own psychology. In the next paper we want to examine the implications of these ideas for clinical training References * Marzillier, J. (2004). ‘The myth of evidence-based psychotherapy’, The Psychologist, July 2004 * Schon, D. (1983). The Reflective Practioner. New York: Basic Books Address Dr Joe Kiff, c/o Psychology Dept, Cross Street Health Centre, Cross St., Dudley, DY1 1RN. ; joe.kiff@dudley.nhs.uk Word count 2300